25 August 2020
This article is authored by
Robert Horne, Professor of Behavioural Medicine at the University College London (UCL) School of Pharmacy where he is Director of the Centre for Behavioural Medicine. Professor Horne is also Founder and Director of Spoonful of Sugar, a UCL Business company.
Professor Horne’s research focuses on the role of psychological and behavioural factors in explaining variation in response to treatment. He has developed a range of tools and models for assessing patient perspectives of illness and treatment for understanding treatment-related behaviours with a particular focus on adherence to medication. Studies are ongoing in a range of long-term conditions including asthma.
Over-reliance on SABA therapy common across all asthma severities
Asthma is a chronic, variable, inflammatory disease that has traditionally been treated using a combination of a bronchodilator providing symptom relief (a reliever) and an inhaled corticosteroid (ICS) to reduce airway inflammation and prevent asthma attacks.1
For safety reasons, the Global Initiative for Asthma (GINA) no longer recommends treatment of asthma with a SABA (short-acting beta2 agonist) alone.1 Instead, to reduce the risk of serious exacerbations, all asthma patients should receive ICS-containing treatment either symptom-driven for mild asthma, or daily for moderate to severe disease.1
Despite this updated recommendation, many asthma patients continue to over-rely on and overuse their SABA inhaler, putting them at a greater risk of asthma attacks, hospitalisation and even premature death.1,2 The problem of patients’ over-reliance on SABA therapy along with underuse of an ICS is not just confined to those with mild asthma, it is a serious issue across all severities.3-5
The use of three or more SABA canisters per year is associated with an increased risk of severe exacerbations1 and using 12 or more canisters in a year is associated with increased risk of asthma-related death.1
At the outset of the COVID-19 pandemic, it was anticipated that people with asthma would be at higher risk of contracting COVID-19, but emerging data are inconsistent.6 It is also unclear whether people with asthma in general are at an increased risk of complications.6 However, at a time when COVID-19 has put a huge strain on healthcare resources, where possible hospital capacity needs to be safeguarded – it has never been more important to empower patients to effectively self-manage their asthma.6
Medical experts agree that to reduce the risk from COVID-19, people need to manage their asthma as well as possible.6 By breaking the cycle of SABA over-reliance, we can ensure asthma patients are able to more effectively self-manage their asthma.
But changing beliefs and behaviours is challenging
Reducing SABA over-reliance is challenging and requires changes in the behaviours of both clinicians and patients. For many clinicians, this may represent a fundamental change in their practice from years of recommending SABA therapy for patients with milder forms of asthma, to recommending 'as needed' low dose ICS-formoterol as the preferred reliever due to its anti-inflammatory properties.1
There are also systemic challenges. In many countries, national prescribing and dispensing systems are ‘hard-wired’ to enable SABA over-reliance through repeat prescriptions and over-the-counter access. This is particularly problematic if repeat prescriptions mean missed opportunities for healthcare professionals to review treatment regimens.7 We therefore need greater awareness and monitoring of SABA use by all asthma patients.7
For patients, simply being provided with information about the change in treatment recommendations is unlikely to alter their behaviour.8 Many patients understandably feel ‘attached’ to their SABA inhaler, mistakenly believing its usage is the best way to control their symptoms.9,10 They will need to be convinced of their personal need to change treatments. Moreover, they are often unaware that over-reliance on their SABA to relieve symptoms is now considered a risk to their health.1,3
A new tool designed to help improve asthma management
Evidence shows that discussions between healthcare professionals and patients to improve the effectiveness of asthma self-management are likely to be more effective if they take account of the patient’s perspective of asthma and its treatment and understand the underlying beliefs influencing how they use their treatment to manage their asthma.11,12,13
Currently, there are no validated methods available to systematically assess the beliefs that are likely to drive over-reliance on SABA. The SABA Reliance Questionnaire (SRQ)* was developed to assess patient perceptions about their personal need for SABA and whether they see SABA as the best way to manage their asthma.
The SRQ is a novel questionnaire assessing patients’ beliefs about SABA that might lead them to be overly reliant on it, and thus inform health interventions to reduce inappropriate medication use and improve asthma management.10
The SRQ is designed to help patients reflect on how they perceive SABA relative to controller therapy and to make them aware of attitudes that might lead them to be overly reliant on their SABA, so that they tend to use SABA as the mainstay of their asthma management strategy with too much SABA and too little anti-inflammatory treatment. It is designed to support discussions between patients and healthcare professionals and assist in breaking the cycle of SABA over-reliance.10
In a paper published in The Journal of Allergy and Clinical Immunology: In Practice, the SRQ was evaluated in 446 patients with self-reported asthma.10 Results demonstrated that the SRQ had acceptable internal reliability, and criterion validity, supporting its potential use as a pragmatic tool for identifying patients whose beliefs are indicative of over-reliance on SABA for asthma.10 The SRQ assesses patients' views about their personal need for SABA and is derived from the Beliefs about Medicines Questionnaire, an internationally recognised, valid and reliable measure of patients’ beliefs about treatment that has been widely used in asthma 14,15,16,17
The SRQ is available for use as part of asthma consultations, where healthcare professionals can screen patients for SABA over-reliance, and target behaviour change interventions to those at highest risk, in a way that is individualised to the patient’s unique beliefs about SABA treatment. It represents an important first step towards addressing the global issue of SABA over-reliance.10
Supporting patients to use the SRQ with the Reliever Reliance Test
The Reliever Reliance Test (RRT) is a new patient-friendly tool, available in digital and paper formats, which is adapted from, and builds on, the validated SABA Reliance Questionnaire (SRQ).10,18 The RRT has two parts: (1) The SRQ - a set of five simple questions, assessing patients beliefs about their personal necessity for SABA and whether they see SABA use as the best way of managing their asthma. (2) Contextual information to help patients understand what their personal questionnaire responses might mean for them.18 This information is designed to raise awareness of the problem of SABA overuse and to encourage them to reflect on whether their perceptions of SABA may be causing them to over-rely on it, and to encourage them to discuss their asthma control with their healthcare professional. It also provides advice about the correct use of SABA inhalers. Patients can even download the results of the test to take to their doctor, nurse, or pharmacist to support a conversation about their asthma management.
Click here to read ‘The SABA Reliance Questionnaire (SRQ): a novel screening tool to identify patients’ beliefs underpinning over-reliance on short-acting beta2 agonists in the management of asthma’ published in The Journal of Allergy and Clinical Immunology: In Practice
*The SABA Reliance Questionnaire (SRQ): a novel screening tool to identify patients’ beliefs underpinning over-reliance on short-acting beta2 agonists in the management of asthma study was supported by Spoonful of Sugar Ltd, a UCL Business spin-out company, in collaboration with IPCRG and Asthma Right Care, with funding from AstraZeneca. AstraZeneca had no part in the design, data collection, analysis, or interpretation of the study data.
1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2020 Update. Available at:
2. Asthma UK. Asthma Attacks. 2020. Available at: https://www.asthma.org.uk/advice/asthma-attacks/
3. FitzGerald JM, Tavakoli H, Lynd LD, et al. The impact of inappropriate use of short acting beta agonists in asthma. Respir Med. 2017;131:135–40.
4. Asthma UK. Patient safety failures in asthma care: the scale of unsafe prescribing errors in the UK. 2015. Available at:
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6. Centre for Evidence-Based Medicine. Asthma and COVID-19: risks and management considerations. Available at:
https://www.cebm.net/covid-19/asthma-and-covid-19-risks-and-management-considerations/. [Accessed July 2020].
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http://www.reliever-quality-standard2019.com/RelieverQualityStandard.pdf [Access June 2020]
8. Kelly MP, Barker M. Why is changing health-related behaviour so difficult? Public health. 2016; 136: 109-16.
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10. Chan AHY, Katzer C, Horne R, , et al. SABA Reliance Questionnaire (SRQ): a novel screening tool to identify patients’ beliefs underpinning over-reliance on short-acting beta2 agonists in the management of asthma. The Journal of Allergy and Clinical Immunology: In Practice. 2020; [IN PRESS]
11. Pinnock H. Supported self-management for asthma. Breathe (Sheff). 2015; 11 (2): 98-109.
12. Bidad N, Barnes N, Griffiths C, Horne R. Understanding patients' perceptions of asthma control: a qualitative study. Eur Respir J 2018; 51(6): 1701346.
13. Ostrem A, Horne R. Reducing asthma attacks: consider patients' beliefs. NPJ primary care respiratory medicine 2015; 25: 15021.
14. Chapman S, Dale P, Svedsater H, et al. Modelling the effect of beliefs about asthma medication and treatment intrusiveness on adherence and preference for once-daily vs. twice-daily medication. NPJ primary care respiratory medicine 2017; 27(1): 61.
15. Menckeberg TT, Bouvy ML, Bracke M, et al. Beliefs about medicines predict refill adherence to inhaled corticosteroids. Journal of psychosomatic research 2008; 64(1): 47-54.
16. Horne R, Weinman J. Self-regulation and self-management in asthma: Exploring the role of illness perceptions and treatment beliefs in explaining non-adherence to preventer medication 5545. Psychology and Health 2002; 17(1): 17-32.
17. Horne R, Weinman J, Hankins M. The Beliefs about Medicines Questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychology & health 1999; 14: 1-24.
18. International Primary Care Respiratory Group Blue Reliever Reliance Test. Available at:
https://www.ipcrg.org/resources/search-resources/blue-reliever-reliance-test-english [Last accessed: July 2020]
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